Malignant breast lesion

Case Case PresentationPresentation

Radiology HMCRadiology HMC

PATIENT PROFILE

• Age : 50yr

• Gender : Female

• Address : Peshawar

• Profession : House wife

CHIEF COMPLAINTS

• Mass in right breast 8 months

• Pain in right breast 1 month

• PAST MEDICAL/ SURGICAL Hx

• MENSTRUAL/OBSTETRICAL Hx

• DRUG Hx

• FAMILY Hx

LUMP EXAMINATION

Location Upper inner quad.

Size 3x2 cm

Appearance Normal

Temperature Normal

Tenderness Present

Margins Irregular

Consistency Hard

Motility Immobile

AXILLARY LYMPH NODES

• Palpable nodes

• In right axilla

• Anterior group

• 1-2 cm size

ULTRASOUND BREAST

Well defined, rounded lesion 2.2x2 cmHeterogenous parenchymaIrregular marginEchogenic foci--- microcalcifications

MAMMOGRAPHY

Superiomedial Well defined roundRadiopaque Foci of calcification + parenchymal distortionMicrocalcifications dispersed in parenchyma

DIAGNOSIS ???DIAGNOSIS ???

MALIGNANT BREAST LESION.

RISK FACTORSRISK FACTORS• Female gender

• Aging

• Genetic factors• BRCA 1&2• P53• PTEN• CHEK2

• Family history of breast ca

• Past hx of breast cancer

• Breast diseases • Atypical hyperplasia• Carcinoma in situ

• Menstrual hx• Early menarche,• late menopause

• Nulliparous

• Lack of breast feeding

• Late age pregnancy

• Drugs • Oral contraceptives • Diethlystilbesterol

• Chest radiation

• Metabolic • Obese• Alcohol • Fat

RADIOLOGICAL TOOLS IN RADIOLOGICAL TOOLS IN DIAGNOSINGDIAGNOSING

– Ultrasound– Mammography– MRI– PET– Complex cyst aspiration– FNAC– Core biopsy– Ductography

ULTRASOUNDULTRASOUND

INDICATIONS

• Symptomatic breast lumps in women aged less than 35 years.

• Breast lump developing during pregnancy or lactation.

• Assessment of mammographic abnormality (± further mammographic views)

• Assessment of MRI or scintimammography detected lesions.

• Clinical breast mass with negative mammograms.

• Breast inflammation.

• The augmented breast (together with MRI).

• Breast lump in a male (together with mammography).

• Guidance of needle biopsy or localisation.

• Follow-up of breast cancer treated with adjuvant chemotherapy.

BenignBenign CharacteristicsCharacteristics

• Ellipsoid shape

• Thin definable capsule

• Two or three lobulations

• Hyperechogenicity.

Malignant Malignant CharacteristicsCharacteristics

• Solid

• Irregular shape

• Irregular borders

• Almost anechoic

•Angular margin

•Taller than wide

•Thick echogenic rim

•Posterior shadowing

BENIGN MALIGNANT

Shape Oval/ellipsoid Variable

Alignment Wider than deep;aligned parallel to tissue planes

Deeper than wide

Margins Smooth/thinechogenic pseudocapsule2-3 gentle lobulations

Irregular or spiculated; echogenic 'halo'

Echotexture Variable to intense hyperechogenicity

Low-levelMarked hypoechogenicity

Homogeneity of internal echoes

Uniform Non-uniform

Lateral shadowing Present Absent

Posterior effect Minimum attenuation/posterior enhancement

Attenuation with obscured posterior margin

Other signs -------------- Calcification

Microlobulation

Intraductal extension

Infiltration across tissue planes

Increased echogenicity of surrounding fat

Fibroadenoma

Homogeneous internal echoes with an ovoid shape and circumscribed margins – benignThere is posterior acoustic enhancement..

A typical 'tall' irregular spiculated hypoechoic attenuating mass in keeping with a malignant breast tumour.

Invasive lobular carcinoma presenting as areas of scattered indeterminate attenuation.

Inflammatory breast cancer with secondary signs.increased hyperechogenicity of the intramammary fat resulting in loss of the normal glandular adipose differentiation Lymphatic dilation is also apparent under the thickened subcutaneous layer.

A power Doppler image of invasive grade 3 breast cancer. irregular tortuous vessels penetrating into the centre of the lesion.

MammographyMammography

INDICATIONS

• Screening asymptomatic >50yrs

• Screening high risk asymptomatic >35yrs

• Symptomatic >35yrs with lump/ cancer

• Surveillance after excision of cancer

• Evaluation after augmentation mammoplasty

• Suspicious breast lump in man

CHARACTERISTICS

• SPICULATE MASS

– Commonest appearance of invasive Ca

– Central soft tissue tumor

– Spicules extending to surrounding

Spiculate mass due to invasive carcinoma

Lateral viewLocalized compression magnification view

• ARCHITECTURAL DISTORTION

– Numerous straight lines

– 1 to 4 cm long

– Radiating towards centre

Stellate lesion due to invasive tubular carcinoma

ASYMMETRICAL SOFT TISSUEDENSITY

Areas of

• Low soft tissue density

• Lucency

• Curvilinear margins

Soft tissue density with irregular margins

CIRCUMSCRIBED MASS

• DENSITY– Radiopaque

• CONTOUR– Ill defined

• NUMBER– Solitary

Circumscribed soft tissue mass showing intracystic carcinoma

Phyllodes tumor. Circumscribed mass with lobulated outline

1. Poorly defined spiculate mass.. Invasive ductal Ca2. Circumscribed soft tissue mass..mucinous Ca

Circumscribed retroareolar mass, poorly defined posterior marginInvasive ductal Ca

MICROCALCIFICATIONS

• Ductal

– Variable in density.

– Variable in shape like linear, casting, branching, irregular

– Distribution With in one lobe/segment

Ductal Carcinoma in situ ,irregular linear branching calcifications

Ductal Carcinoma in situIrregular pleomorphic calcification

EDEMATOUS BREAST

• Thickened skin

• Increased density

• Coarse trabecular pattern

• Enlargement of breast

MRIMRI

INDICATIONS • Staging biopsy-proven primary breast

carcinoma

• Detecting an occult primary breast cancer in a patient with proven axillary node involvement but negative results on mammography and ultrasonography

• Ascertaining the extent of disease after lumpectomy with positive margins or close margins

• Investigating suspected pectoralis muscle invasion

• Assessing response to chemotherapy, including preoperative chemotherapy

• Looking for suspected recurrent disease, such as in a postsurgical scar

• A compelling clinical presentation with negative or equivocal imaging results

• Problem solving, ie, workup of uncertain imaging findings that could not be resolved even after special mammographic and ultrasonographic techniques were used

• Needle localization and guided biopsy

• Known or suspected rupture of breast implants

• Screening patients with certain well-defined risk factors for breast cancer.

Dense breast tissue Two lesions on contrast enchanced MRI

Biopsy proven case of breast carcinoma

Pre contrastPre contrast Post contrastPost contrast

Sagittal T1 weighted gradient-echo images with fat saturationSagittal T1 weighted gradient-echo images with fat saturationIntravenous gadolinium-DTPA.Intravenous gadolinium-DTPA.2 malignant masses2 malignant massesTypical heterogenous and rim enhancement of larger massTypical heterogenous and rim enhancement of larger massInvolvement of prepectoral fascia,pectoralis major andInvolvement of prepectoral fascia,pectoralis major andskin by inferior massskin by inferior mass

BI-RADSBI-RADS• Breast Imaging Reporting And Data

System

• Made by American college of radiology

• Importance – Diagnostic– Therapeutic – Prognostic– Epidemiologic – Standardized words in mammographic

reporting– Improved communication

BI-RADS assessment BI-RADS assessment categoriescategories

• Category 0

• Category 1

• Category 2

• Category 3

• Category 4

• Category 5

• Category 6

Category 0Category 0

• Assessment incomplete

• Further workup needed

• e.g Screening mammogram shows a nodule…..

• Till further workup its labelled as category 0

Category 1Category 1• Negative

• mammogram shows– No grouped or suspicious

microcalcifications

– No well-formed mass,

– A symmetrical glandular structure

– No change from any previous exam

Category 2Category 2

• definitely benign and a routine screening

• It include:

– Round opacities with macrocalcifications (typical calcified fibroadenoma or cyst)

– Round opacities corresponding to a typical cyst at ultrasonography

– Oval opacities with a radiolucent center

– Fatty densities or partially fatty images (lipoma, galactocele, oil cyst, hamartoma )

– Vascular calcifications

– Scattered macrocalcifications (fibroadenoma, cyst, cytosteatonecrosis, secretory ductal ectasia);

– Breast implants,silicone granuloma.

– Surgical scar

Category 3Category 3

• Probably Benign

• Positive predictive value less than 1%

• a follow-up of 6 months is usually recommended.

Findings include:

• Clusters of tiny calcifications if round or oval

• Non-calcified solid nodules (no size limitation but non palpable), round, ovoid, well-defined,

• Selected focal asymmetric areas of fibroglandular density (not palpable):

• Miscellaneous focal findings, such as a dilated duct, or post biopsy architectural distortion without central density

• Generalized distribution in both breasts. For example, multiple similar lesions with tiny calcifications or nodules distributed randomly

• In some scenerios a percutaneous biopsy might be considered,even with category 3. For example, extreme patient anxiety, or plans for pregnancy, plans for breast augmentation or reduction surgery, or if synchronous carcinoma is present

indeterminate BI-RADS 3 and not BI-RADS 2, because of the poorly defined, fuzzy edge.

Category 4Category 4

• Suspicious or Indeterminate abnormality

• The positive predictive value (the chance of a real cancer) 20-40%.

• Commonly fibrocystic changes

• A biopsy should be recommended.

It is often subdivided into three smaller sub-categories:

– "A" for low suspicion of malignancy,

– "B" for moderate suspicion,

– "C" for high suspicion.

Findings include: • Asymmetric, localized or evolving

hyperdensities with convex contours. • Indeterminate microcalcifications

appearing amorphous, indistinct particularly if in a cluster or heterogeneous and pleomorphic

• Round or oval non cystic opacities with microlobulated or obscured contours

Category 5Category 5• Highly suggestive of malignancy

• A biopsy should be taken immediately.

• Positive predictive value 95%

Finding include :

• Typically malignant microcalcifications; e.g.linear with branching pattern;

• Clusters of microcalcifications with a segmental or galactophorous distribution

• Evolving microcalcifications or associated

with an architectural distortion or opacity

• Poorly circumscribed opacities;

• Spiculated opacities with radio-opaque center.

Category 6Category 6• Known Cancer

• Proven by biopsy. • Used when patients undergoing breast

cancer treatment have follow-up mammograms.

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